Adult Acute Mental Health Unit, University Hospital Galway · The Adult Acute Mental Health Unit,...

2018 COMPLIANCE RATINGS

26

4 1 2

1

11

2

1

Inspection Team:

Susan O'Neill, Lead Inspector

Martin McMenamin

Carol Brennan Forsyth

Karen McCrohan

Inspection Date: 27 – 30 November 2018

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: N/a

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: Thursday 25 April 2019

RULES AND PART 4 OF THE MENTAL HEALTH

ACT 2001

Compliant

Adult Acute Mental Health Unit, University Hospital Galway

ID Number: AC0105

2018 Approved Centre Inspection Report (Mental Health Act 2001)

Adult Acute Mental Health Unit

University Hospital Galway

Newcastle Road

Galway

Approved Centre Type:

Acute Adult Mental Health Care Psychiatry of Later Life Mental Health Rehabilitation Mental Health Care for People with Intellectual Disability

Most Recent Registration Date:

30 June 2018

Conditions Attached: None

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Mr Steve Jackson, General Manger

CHO2 – Mental Health Services

j

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

AC0105 Adult Acute Mental Health Unit, University Hospital Galway Approved Centre Inspection Report 2018 of 83

RATINGS SUMMARY 2016 – 2018

Compliance ratings across all 39 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2016 – 2018

Please note: The approved centre opened in June 2018.

Where non-compliance is determined, the risk level of the non-compliance will be assessed. Risk ratings

across all non-compliant areas are summarised in the chart below.

Chart 2 – Comparison of overall risk ratings 2016 – 2018

Please note: The approved centre opened in June 2018.

3

7

29

0

5

10

15

20

25

30

35

40

45

2018

Not applicable Non-compliant Compliant

1

2

4

0

1

2

3

4

5

6

7

8

2016 2017 2018

Low Moderate High Critical


Contents 1.0 Introduction to the Inspection Process ............................................................................................ 4

2.0 Inspector of Mental Health Services – Review of Findings .............................................................. 6

3.0 Quality Initiatives ............................................................................................................................. 9

4.0 Overview of the Approved Centre ................................................................................................. 10

4.1 Description of approved centre ............................................................................................. 10

4.2 Conditions to registration ...................................................................................................... 10

4.3 Reporting on the National Clinical Guidelines ....................................................................... 11

4.4 Governance ............................................................................................................................ 11

4.5 Use of restrictive practices ..................................................................................................... 11

5.0 Compliance ..................................................................................................................................... 12

5.1 Non-compliant areas on this inspection ................................................................................ 12

5.2 Areas of compliance rated “excellent” on this inspection ..................................................... 12

5.3 Areas that were not applicable on this inspection ................................................................ 13

6.0 Service-user Experience ................................................................................................................. 14

7.0 Feedback Meeting .......................................................................................................................... 15

8.0 Inspection Findings – Regulations .................................................................................................. 16

9.0 Inspection Findings – Rules ............................................................................................................ 59

10.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 64

11.0 Inspection Findings – Codes of Practice ....................................................................................... 67

Appendix 1: Corrective and Preventative Action Plan Template……………………………………………………….74

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The principal functions of the Mental Health Commission are to promote, encourage and foster the

establishment and maintenance of high standards and good practices in the delivery of mental health

services and to take all reasonable steps to protect the interests of persons detained in approved centres.

The Commission strives to ensure its principal legislative functions are achieved through the registration and

inspection of approved centres. The process for determination of the compliance level of approved centres

against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent

and standardised.

Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function of the

Inspector shall be to “visit and inspect every approved centre at least once a year in which the

commencement of this section falls and to visit and inspect any other premises where mental health services

are being provided as he or she thinks appropriate”.

Section 52 of the 2001 Act states that, when making an inspection under section 51, the Inspector shall

a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine

by the resident himself or herself or by any other person.

b) See every patient the propriety of whose detention he or she has reason to doubt.

c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other

premises where mental health services are being provided, to this Act and the provisions made

thereunder.

d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60

and the provision of Part 4 are being complied with.

Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001

Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of

documentation review, observation and interview to assess compliance with the requirements. Where non-

compliance is determined, the risk level of the non-compliance will be assessed.

The Inspector will also assess the quality of services provided against the criteria of the Judgement Support

Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out

exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of

Regulations 28, 33 and 34 a quality assessment is not required.

Following the inspection of an approved centre, the Inspector prepares a report on the findings of the

inspection. A draft of the inspection report, including provisional compliance ratings, risk ratings and quality

assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are

deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate,

high or critical.

1.0 Introduction to the Inspection Process


The registered proprietor is given an opportunity to review the draft report and comment on any of the

content or findings. The Inspector will take into account the comments by the registered proprietor and

amend the report as appropriate.

The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA) plan for each

finding of non-compliance in the draft report. Corrective actions address the specific non-compliance(s).

Preventative actions mitigate the risk of the non-compliance reoccurring. CAPAs must be specific,

measurable, achievable, realistic, and time-bound (SMART). The approved centre’s CAPAs are included in

the published inspection report, as submitted. The Commission monitors the implementation of the CAPAs

on an ongoing basis and requests further information and action as necessary.

If at any point the Commission determines that the approved centre’s plan to address an area of non-

compliance is unacceptable, enforcement action may be taken.

In circumstances where the registered proprietor fails to comply with the requirements of the 2001 Act,

Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made under the 2001 Act, the

Commission has the authority to initiate escalating enforcement actions up to, and including, removal of an

approved centre from the register and the prosecution of the registered proprietor.

COMPLIANCE, QUALITY AND RISK RATINGS The following ratings are assigned to areas inspected:

COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are generally given for all regulations, except for 28, 33 and 34. RISK RATINGS are given for any area that is deemed non-compliant.

COMPLIANCE RATING

COMPLIANT

EXCELLENT

LOW

QUALITY RATING

RISK RATING

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL


Inspector of Mental Health Services Dr Susan Finnerty As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings

below.

This summary is based on the findings of the inspection team under the regulations and associated

Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user

experience, staff interviews and governance structures and operations, all of which are contained in this

report.

In brief The Adult Acute Mental Health Unit, University Hospital Galway was a newly built two-storey facility, located

on the grounds of the University Hospital Galway site. The approved centre was registered for 50 beds on

30th June 2018 and consisted of four separate wards, Hazel, Ash, Holly and Oak. Twelve consultant led teams,

including two Psychiatry of Later Life teams, Mental Health Intellectual Disability team, and Rehabilitation

and Recovery team, referred residents to the approved centre.

The approved centre was compliant with 81% of regulations, rules and codes of practice. Compliance with

nine regulations was rated as excellent. There were no conditions attached to the registration of the

approved centre.

Safety in the approved centre Food safety audits were carried out and the kitchen areas were clean. A system of using two patient

identifiers was in place. Ligature points had been minimised. Medication was ordered, prescribed, stored

and administered in a safe manner. A comprehensive risk management policy was implemented; however,

not all staff were trained in Basic Life Support, fire safety, management of aggression and violence and the

Mental Health Act.

Appropriate care and treatment of residents

Each resident had an individual care plan that was multi-disciplinary and developed with the resident.

Therapeutic services and programmes were provided in line with the needs of residents, which were

identified in their care plans. A new group activity facilitated by an approved centre doctor had been

introduced. This group, entitled “My Hour, My Time”, enabled residents to discuss various issues of concern

in a group forum.

Physical health was assessed at admission and regularly thereafter. ECT was administered in accordance with

the relevant rules and code of practice. In two episodes of physical restraint, there was no record to indicate

that the resident had received a medical exam at all by a registered medical practitioner within three hours

after the start of an episode of physical restraint. In one case, while a medical exam did take place, there

2.0 Inspector of Mental Health Services – Review of Findings


was no time record to show that it took place within three hours after the start of the physical restraint

episodes.

The approved centre complied with Part 4 of the Mental Health Act Consent to Treatment. Discharge

processes were unsatisfactory and did not ensure that prompt information was provided to the resident’s

GP following discharge.

Respect for residents’ privacy, dignity and autonomy The majority of bedrooms were single en suite rooms. Hazel suite contained one three-bedded and two two-

bedded rooms and Ash suite contained one three-bedded room and one two-bedded room. The

entrance/exit door of the acute unit was locked at all times and was opened by staff using an electronic

swipe card system. This was a mechanism used to ensure the safety and welfare of the residents, and as a

means of security.

Residents could meet their visitors in private. They wore their own clothes and maintained control over their

own property.

CCTV cameras used to observe residents were capable of recording or storing a resident’s image, and CCTV

cameras were in need of a setting adjustment to have the setting changed to non-recording.

Residents on Oak suite, the high dependency unit, were restricted from using any electronic devices.

Maintenance of resident safety and privacy was the underlying rationale for this practice. Residents on Hazel,

Ash and Holly suites were risk assessed with regard to using their electronic devices.

Residents could access the enclosed garden area freely.

In two seclusion episodes, the resident was not informed of the reasons, duration, and circumstances leading

to discontinuation of seclusion. In two seclusion episodes, the resident was not informed of the ending of an

episode of seclusion, and in one seclusion episode, the reason for ending seclusion was not recorded in the

clinical file.

Responsiveness to residents’ needs The approved centre was new and well maintained internally and externally and was clean. There was

excellent information about the approved centre, residents’ medication and diagnosis provided to residents.

There was a robust complaints procedure in place. There was a good choice of food at mealtimes and healthy

options were available. There was a wide range of recreational activities.

Governance of the approved centre The approved centre was a part of the HSE’s Community Healthcare Organisation (CHO) 2 area. The

approved centre had an organisation chart and clear governance structures and processes in place.


The Clinical Governance team met on a monthly basis and was attended by heads of discipline and services.

The minutes outlined a clear agenda, actions, and review of governance. Several subcommittees reported

into the Clinical Governance meeting including the Health and Safety subgroup, Drugs and Therapeutics

subgroup, Complex Care group, Policy and Procedures subgroup, Audit and Quality improvement group,

Clinical Charts subgroup and Clinical Complaints Committee. Business meetings occurred on a two monthly

basis and were attended by heads of discipline and management. Standing items on the agenda included

Quality, Safety and Risk, Health and Safety, Audit, and Judgement Support Framework compliance.

The Heads of Disciplines outlined regular engagement with staff and they outlined clear lines of

responsibility. The retention of staff, staff training and bed capacity issues were identified, within the

questionnaires, as key operational risks.


The following quality initiatives were identified on this inspection:

1. Development of the Health and Safety Fast Facts Booklet and the Information Fast Finder. These

documents enable staff to refer to issues relating to health and safety or policy and procedure quickly

and efficiently.

2. Introduction of a new group activity facilitated by an approved centre doctor. This group, entitled

“My Hour, My Time”, enables residents to discuss various issues of concern in a group forum.

3. Employment of a resident doctor for the new approved centre.

4. Implementation of emergency simulation training in collaboration with the Resuscitation

Department (University Hospital Galway).

5. Implementation of various practices and initiatives to ensure a smoke free environment. These

included education for residents and staff on tobacco usage, provision of smoking cessation supports

and employment of a dedicated professional to manage and support the smoke free initiative.

6. Introduction of a 24-hour security service within the approved centre.

7. Delivery of new training initiatives including Decider Skills training, Falls Prevention and Management

training and “Train the Trainer” course.

8. Introduction of weekly academic meetings for staff to support continuous professional development.

9. Introduction of whiteboards into all bedrooms for the purposes of displaying relevant information

for each resident.

3.0 Quality Initiatives


4.1 Description of approved centre The Adult Acute Mental Health Unit, University Hospital Galway was a newly built two-storey facility, located

on the grounds of University Hospital Galway site. The approved centre was registered for 50 beds on 30th

June 2018 and consisted of four separate secure wards, Hazel, Ash, Holly and Oak. Twelve consultant led

teams, including two Psychiatry of Later Life teams, Mental Health Intellectual Disability team, and

Rehabilitation and Recovery team, referred residents to the approved centre.

Hazel, Oak and Ash suites were all located on the ground floor and each had access to outdoor space. Hazel

and Ash suite consisted of 18 and 19 beds respectively. The majority of bedrooms were single en suite rooms.

Hazel suite contained one three-bedded and two two-bedded rooms and Ash suite contained one three-

bedded room and one two-bedded room. Both Hazel and Ash suites had access to a shared area, which

contained a dayroom, a games room, a dining area and a quiet room. The Oak suite was a high observation

unit and consisted of five single en suite rooms. The suite also contained a seclusion room and had access

to a separate outdoor garden area.

The Holly suite, located on the first floor, consisted of eight single en suite rooms and was dedicated to

Psychiatry of Later Life. Residents had access to an outdoor enclosed space, which contained seating areas

and multiple plant boxes. The first floor also housed administration/management offices, training rooms, an

Electroconvulsive therapy (ECT) suite and Therapy facilities that included a relaxation room, an art room,

and a therapy kitchen. Therapy facilities were accessed by all residents of the approved centre as

appropriate.

The resident profile on the first day of inspection was as follows:

Resident Profile

Number of registered beds 50

Total number of residents 50

Number of detained patients 19

Number of wards of court 0

Number of children 0

Number of residents in the approved centre for more than 6 months 0

Number of patients on Section 26 leave for more than 2 weeks 2

4.2 Conditions to registration

There were no conditions attached to the registration of this approved centre at the time of inspection.

4.0 Overview of the Approved Centre


4.3 Reporting on the National Clinical Guidelines

The service reported that it was cognisant of and implemented, where indicated, the National Clinical

Guidelines as published by the Department of Health.

4.4 Governance

The approved centre was a part of the HSE’s Community Healthcare Organisation (CHO) 2 area. The

approved centre had an organisation chart and clear governance structures and processes in place. The

minutes of the Clinical Governance team meetings and the Acute Unit Business team meetings were

provided to the inspection team.

The Clinical Governance team met on a monthly basis and was attended by heads of discipline and services.

The minutes outlined a clear agenda, actions, and review of governance. Several subcommittees reported

into the Clinical Governance meeting including the Health and Safety subgroup, Drugs and Therapeutics

subgroup, Complex Care group, Policy and Procedures subgroup, Audit and Quality improvement group,

Clinical Charts subgroup and Clinical Complaints Committee. Business meetings occurred on a two monthly

basis and were attended by heads of discipline and management. Standing items on the agenda included

Quality, Safety and Risk, Health and Safety, Audit, and Judgement Support Framework compliance.

The Mental Health Commission’s Governance Questionnaire was issued to the approved centre. Completed

questionnaires were returned by the Clinical Director, the Business Manager, the Assistant Director of

Nursing, the Occupational Therapy Manager and the Director of Psychology. The Heads of Disciplines

outlined regular engagement with staff and they outlined clear lines of responsibility. The retention of staff,

staff training and bed capacity issues were identified, within the questionnaires, as key operational risks.

4.5 Use of restrictive practices

Throughout this inspection, the entrance/exit door of the acute unit was locked at all times and was opened

by staff using an electronic swipe card system. This was a mechanism used to ensure the safety and welfare

of the residents, and as a means of security.

Residents on Oak suite, the high dependency unit, were restricted from using any electronic devices.

Maintenance of resident safety and privacy was the underlying rationale for this practice. Residents on Hazel,

Ash and Holly suites were risk assessed with regard to using their electronic devices.


5.1 Non-compliant areas on this inspection

Non-compliant (X) areas on this inspection are detailed below alongside the risk rating.

The approved centre opened in June 2018; therefore, this was the first inspection.

Regulation/Rule/Act/Code Compliance/Risk Rating 2018

Regulation 25: Use of Closed Circuit Television X Moderate

Regulation 26: Staffing X High

Regulation 27: Maintenance of Records X Low

Regulation 28: Register of Residents X High

Rules Governing the Use of Seclusion X Moderate

Code of Practice on the Use of Physical Restraint in Approved Centres X High

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre

X High

The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-

compliance. These are included in Appendix 1 of the report.

5.2 Areas of compliance rated “excellent” on this inspection

Regulation

Regulation 4: Identification of Residents

Regulation 5: Food and Nutrition

Regulation 6: Food Safety

Regulation 7: Clothing

Regulation 8: Resident’s Personal Property and Possessions

Regulation 10: Religion

Regulation 12: Communication

Regulation 13: Searches

Regulation 30: Mental Health Tribunals

5.0 Compliance


5.3 Areas that were not applicable on this inspection

Regulation/Rule/Code of Practice Details

Regulation 17: Children’s Education As the approved centre had not admitted any children since it opened five months prior to this inspection, this regulation was not applicable.

Rules Governing the Use of Mechanical Means of Bodily Restraint

As the approved centre did not use mechanical means of bodily restraint, this rule was not applicable

Code of Practice Relating to Admission of Children Under the Mental Health Act 2001

As no children had been admitted to the approved centre since it first opened in 2018, this code of practice was not applicable.


The Inspector gives emphasis to the importance of hearing the service users’ experience of the approved

centre. To that end, the inspection team engaged with residents in a number of different ways:

The inspection team informally approached residents and sought their views on the approved centre.

Posters were displayed inviting the residents to talk to the inspection team.

Leaflets were distributed in the approved centre explaining the inspection process and inviting

residents to talk to the inspection team.

Set times and a private room were available to talk to residents.

In order to facilitate residents who were reluctant to talk directly with the inspection team, residents

were also invited to complete a service user experience questionnaire and give it in confidence to

the inspection team. This was anonymous and used to inform the inspection process.

The Area Lead from the HSE Mental Health Engagement Office was contacted.

With the residents’ permission, their experience was fed back to the senior management team. The

information was used to give a general picture of residents’ experience of the approved centre as outlined

below. Additional feedback was received through the MHC resident questionnaires. These were placed on

each unit on the first day of our inspection. In total, two were completed.

The inspection team met with six residents individually to discuss their experience of the service. All the

residents were complimentary of the staff, the level of care they received and the facilities within the

approved centre. Residents were satisfied with the food and menus provided on a daily basis. One resident

mentioned that, occasionally, some of the hot food options were not very nutritious and improvements

could be made. The majority of residents reported some level of engagement with daily activities on the

ward. One resident stated that it would be beneficial if there were some small items of indoor exercise

equipment to use for those days when the weather was too poor to go outdoors to use the exercise

equipment there.

Two feedback questionnaires were completed by residents. These were very positive and complimentary

toward the team. One person commented that they would like more activities on their particular unit. There

were no issues raised requiring urgent attention from management.

6.0 Service-user Experience


A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended by the

inspection team and the following representatives of the service:

The Registered Proprietor Nominee

Clinical Director

Business Manger

Clinical Nurse Manager Grade 3

Clinical Nurse Manager Grade 2, 1 x 2

Assistant Director of Nursing

Psychiatry Consultants, 1 x 5

Principal Social Worker

Occupational Therapy Manager

Senior Clinical Psychologist

Mental Health Administrator

Mental Health Engagement Lead

The inspection team outlined the initial findings of the inspection process and provided the opportunity for

the service to offer any corrections or clarifications deemed appropriate. Specific clarifications or corrections

were not received.

7.0 Feedback Meeting


8.0 Inspection Findings – Regulations

The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions

EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)


Regulation 4: Identification of Residents

The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in November 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for the identification of residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that clinical files contained appropriate resident identifiers. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: A minimum of two resident identifiers appropriate to the resident group profile and individual residents’ needs were used. The approved centre offered residents the option to wear identity wristbands. The identifiers were person-specific and appropriate to the residents’ communication abilities. Two appropriate identifiers were checked before the administration of medication, the undertaking of medical investigations, and the provision of other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. Red warning sticker alerts were used to alert staff to the presence of residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.

COMPLIANT Quality Rating Excellent


Regulation 5: Food and Nutrition

(1) The registered proprietor shall ensure that residents have access to a safe supply of fresh drinking water.

(2) The registered proprietor shall ensure that residents are provided with food and drink in quantities adequate for their needs, which is properly prepared, wholesome and nutritious, involves an element of choice and takes account of any special dietary requirements and is consistent with each resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food and nutrition. It was last reviewed in June 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents were provided with wholesome and nutritious food in line with their needs. Documented analysis had been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: The approved centre’s menus were approved monthly by a dietitian to ensure nutritional adequacy in accordance with the residents’ needs. Residents were offered a variety of wholesome and nutritious food, including portions from different food groups in the Food Pyramid. There was a choice of hot meals daily. Food, including modified consistency diets, was presented in an appealing manner in terms of texture, flavour, and appearance. Residents were offered hot and cold drinks regularly, and fresh water was available from easily accessible locations in the approved centre. Nutritional and dietary needs were assessed, where necessary, and addressed in residents’ individual care plans. The approved centre used an evidence-based nutrition assessment tool to evaluate residents with special dietary requirements. Their special nutritional requirements were regularly reviewed by a dietitian. Intake and output charts were maintained for residents, where appropriate. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 6: Food Safety

(1) The registered proprietor shall ensure:

(a) the provision of suitable and sufficient catering equipment, crockery and cutlery

(b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and

(c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse.

(2) This regulation is without prejudice to:

(a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety;

(b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and

(c) the Food Safety Authority of Ireland Act 1998.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was last reviewed in November 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff were able to articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in food safety commensurate with their role. Staff training was documented, and evidence of certification was available. Monitoring: Food safety audits had been completed periodically. Food temperatures were recorded in line with food safety recommendations, and a temperature log sheet was maintained and monitored. Documented analysis had been completed to identify opportunities to improve food safety processes. Evidence of Implementation: There were proper facilities for the refrigeration, storage, preparation, cooking, and serving of food. Food was prepared in a manner that reduced the risk of contamination, spoilage, and infection. There was suitable and sufficient catering equipment in the approved centre. Hygiene was maintained to support food safety requirements. Residents were provided with crockery and cutlery that was suitable and sufficient to address their specific needs. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 7: Clothing

The registered proprietor shall ensure that:

(1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times;

(2) night clothes are not worn by residents during the day, unless specified in a resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had two written policies in relation to residents’ clothing, which were last reviewed in March 2017. The policies included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy on residents’ clothing. Relevant staff interviewed were able to articulate the processes for residents’ clothing, as set out in the policy. Monitoring: The availability of an emergency supply of clothing for residents was monitored on an ongoing basis. A record of residents wearing nightclothes during the day, as indicated by their individual care plan, was maintained and monitored. Evidence of Implementation: Residents were supported to keep and use personal clothing, which was clean and appropriate to their needs. Residents were provided with emergency personal clothing that was appropriate and took into account their preferences, dignity, bodily integrity, religious, and cultural practices. These were tracksuits and new underwear. Residents had an adequate supply of individualised clothing. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 8: Residents’ Personal Property and Possessions

(1) For the purpose of this regulation "personal property and possessions" means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents' personal property and possessions.

(3) The registered proprietor shall ensure that a record is maintained of each resident's personal property and possessions and is available to the resident in accordance with the approved centre's written policy.

(4) The registered proprietor shall ensure that records relating to a resident's personal property and possessions are kept separately from the resident's individual care plan.

(5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident's individual care plan.

(6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to residents’ personal property and possessions, which was last reviewed in October 2016. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff were able to articulate the processes for residents’ personal property and possessions, as set out in the policy. Monitoring: Personal property logs were monitored in the approved centre. Documented analysis had been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions. Evidence of Implementation: On admission, the approved centre compiled a detailed property checklist with each resident of their personal property and possessions. This property checklist was kept separate from the resident’s individual care plan (ICP). The checklist was updated on an ongoing basis in accordance with the approved centre’s policy. Secure facilities were provided for the safekeeping of the residents’ monies, valuables, personal property, and possessions. Residents had access to locked cupboards in their rooms, and there were secure property rooms in all suite areas. Residents were encouraged to send valuables home. Large amounts of money could be lodged to the administration office in the main hospital building. Residents were encouraged to keep small amounts only. Where any money belonging to residents was handled by staff, signed records of staff issuing the money were retained and countersigned by the resident or their representative, where possible. Residents were supported to manage their own property, unless this posed a danger to themselves or to others, as indicated in their ICPs. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 9: Recreational Activities

The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in October 2017. The policy included the requirements of the Judgement Support Framework with the exception of a description of the facilities available for recreational activities, including the identification of suitable locations for recreational activities within and external to the approved centre. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a record of resident uptake and attendance. Documented analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided access to recreational activities appropriate to the resident group profile on weekdays and during the weekend. Accessible and suitable information on the activities available to residents was provided in the information booklet that each resident received on admission. The timetable for activities was displayed on noticeboards and whiteboards throughout the approved centre. Activities included TV, books, puzzles, board games, and a games room with a pool table. Staff organised resident groups including a walking group, a pool tournament, a newspaper group, and a quiz. Recreational activities were appropriately resourced, and opportunities were available for indoor and outdoor exercise and physical activity. The approved centre offered access to a courtyard with outdoor gym equipment, and all units within the approved centre had direct access to a spacious enclosed garden. Records of resident attendance at events were maintained in group records or in the clinical files. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes pillar.

COMPLIANT Quality Rating Satisfactory


Regulation 10: Religion

The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in October 2016. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy to support residents’ religious practices was reviewed to ensure that it reflected the identified needs of residents. This was documented. Evidence of Implementation: Residents’ religious beliefs were assessed at admission. Their rights to practice religion were facilitated and supported. Residents had access to multi-faith chaplains, if required. The hospital chaplain visited the unit periodically and on request. Holy Communion was available daily on the unit. Residents had access to local religious services and they were supported to attend, if deemed appropriate following a risk assessment. The care and services provided within the approved centre were respectful of residents’ religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 11: Visits

(1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident.

(2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits.

(3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors.

(4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan.

(5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident.

(6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to visits, which was last reviewed in June 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy. Monitoring: There were no restrictions on residents’ rights to receive visitors in place at the time of the inspection. As the approved centre had recently opened at the time of the inspection, analysis to identify opportunities to improve visiting processes was deemed not applicable. Evidence of Implementation: Appropriate and reasonable visiting times were publicly displayed in each suite of the approved centre. Clinical files documented the names of visitors the resident did not wish to see and those who posed a risk to the resident. Separate visiting rooms in the reception area, Holly and Oak suites were provided where residents could meet visitors in private, unless there was an identified risk to the resident or others or a health and safety risk. It was possible for visits to take place in the quiet room, which was shared between Ash and Hazel suites. Appropriate steps were taken to ensure the safety of residents and visitors during visits. Children could visit, if accompanied by an adult and supervised at all times. This was communicated to all relevant individuals publicly. The visiting room available was suitable for visiting children, and there was a selection of colouring books for children to colour in. The approved centre was compliant with this regulation. As all requirements of the monitoring pillar were deemed not applicable, Regulation 11: Visits, was only assessed under the three pillars of processes, training and education and evidence of implementation.

COMPLIANT


Regulation 12: Communication

(1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health.

(2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication.

(4) For the purposes of this regulation "communication" means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to resident communication, which was last reviewed in March 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for communication, as set out in the policies. Monitoring: Resident communication needs and restrictions on communication were monitored on an ongoing basis. Documented analysis had been completed to identify ways of improving communication processes. Evidence of Implementation: Residents had access to mail, fax, internet, and telephone if they wished. A computer room was accessible to residents seven days a week. Residents in the high dependency unit were restricted from using any electronic devices, in the interest of their safety. Individual risk assessments were completed for residents, as deemed appropriate, in relation to any risks associated with their external communication. This was documented in the individual care plan. The authorised senior staff member only examined incoming and outgoing resident communication if there was reasonable cause to believe the communication may result in harm to the resident or to others. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 13: Searches

(1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated.

(2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent.

(4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought.

(5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching.

(6) The registered proprietor shall ensure that there is be a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted.

(7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident's dignity, privacy and gender.

(8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why.

(9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search.

(10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the implementation of resident searches, which was last reviewed in October 2018. The policy addressed all of the requirements of the Judgement Support Framework, including the following:

The management and application of searches of a resident, his or her belongings, and the environment in which he or she is accommodated.

The consent requirements of a resident regarding searches and the process for carrying out searches in the absence of consent.

The process for dealing with illicit substances uncovered during a search. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for searches, as set out in the policy. Monitoring: A log of searches was maintained. Each search record was systematically reviewed to ensure the requirements of the regulation had been complied with. A documented analysis had been completed to identify opportunities for improvement of search processes. Evidence of Implementation: The resident search policy and procedure was communicated to all residents. Searches were only conducted for the reason of creating and maintaining a safe and therapeutic environment for residents and staff. General written consent was sought for routine environmental searches. The clinical file of one resident who was searched was inspected. Risk had been assessed prior to the search of the resident, their property, or the environment, appropriate to the type of search being undertaken. The resident’s consent was sought and documented, prior to the search taking place.



The resident was informed by those implementing the search of what was happening during a search and why. There was a minimum of two clinical staff in attendance at all times when the search was being conducted. The search was implemented with due regard to the resident’s dignity, privacy and gender; and at least one of the staff members who conducted the search was the same gender as the resident being searched. Policy requirements were implemented when illicit substances were found as a result of a search. A written record of every search of a resident, and every property search was available. This included the reason for the search, the names of both staff members who undertook the search, and details of who was in attendance for the search. The approved centre was compliant with this regulation. The quality assessment was rated excellent was because the approved centre met all criteria of the Judgement Support Framework.


Regulation 14: Care of the Dying

(1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying.

(2) The registered proprietor shall ensure that when a resident is dying:

(a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs;

(b) in so far as practicable, his or her religious and cultural practices are respected;

(c) the resident's death is handled with dignity and propriety, and;

(d) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(3) The registered proprietor shall ensure that when the sudden death of a resident occurs:

(a) in so far as practicable, his or her religious and cultural practices are respected;

(b) the resident's death is handled with dignity and propriety, and;

(c) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring.

(5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005.

INSPECTION FINDINGS Processes: The approved centre had a written operational policies and protocols in relation to care of the dying. The care of the dying policy was last reviewed in March 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for end of life care, as set out in the policy. As there had been no deaths in the approved centre since the last inspection, the approved centre was only assessed under the two pillars of processes and training and education for this regulation. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 15: Individual Care Plan

The registered proprietor shall ensure that each resident has an individual care plan.

[Definition of an individual care plan:“... a documented set of goals developed, regularly reviewed and updated by the resident’s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation”.]

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development, use, and review of individual care plans (ICPs), which was last reviewed in November 2016. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to individual care planning, as set out in the policy. All multi-disciplinary team (MDT) members had received training in individual care planning. Monitoring: Residents’ ICPs were audited on a quarterly basis to determine compliance with the regulation. Documented analysis had been completed to identify ways of improving the individual care planning process. Evidence of Implementation: Each resident had an ICP, ten of which were inspected. A key worker was identified to ensure continuity in the implementation of a resident’s ICP. The key worker was not consistent throughout the resident’s admission. All ICPs inspected were a composite set of documentation with allocated spaces for goals, treatment, and care. There were no allocated spaces for resources in ICPs; however, resources were referred to under the intervention section of the ICPs. All ICPs were stored in the clinical file, were identifiable and uninterrupted, and were not amalgamated with progress notes. Residents were assessed at admission by the admitting clinician and an initial ICP was completed by the admitting clinician to address the immediate needs of the resident. All residents received an evidenced-based comprehensive assessment within seven days of admission. The ICP was discussed, agreed where practicable, and drawn up with the participation of the resident and their representative, and next of kin, as appropriate. The ICPs identified residents’ assessed needs, defined appropriate goals, and identified the care and treatment required to meet the identified goals. The staff responsibilities and regularity for implementing each resident’s care and treatment was addressed in ICPs. The ICP identified the resources required to provide each resident’s care and treatment identified. Resources were not named individuals, but instead which discipline resources would come from, was recorded on ICPs. The ICP included a risk management plan and a preliminary discharge plan was documented. The ICP was reviewed by the MDT in consultation with the resident regularly. Residents had access to their ICPs and were kept informed of any changes. All residents were offered a copy of their ICP, including any reviews. At times, residents did refuse and decline a copy of their ICP, but their refusal reason was not always detailed.



The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.


Regulation 16: Therapeutic Services and Programmes

(1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan.

(2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident.

INSPECTION FINDINGS Processes: The approved centre had two written policies in relation to the provision of therapeutic services and programmes. The care of residents’ policy was last reviewed in May 2018. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to therapeutic activities and programmes, as set out in the policy. Monitoring: The range of services and programmes provided in the approved centre were monitored on an ongoing basis to ensure that the assessed needs of residents were met. Documented analysis had been completed to identify opportunities for improving the processes relating to therapeutic services and programmes. Evidence of Implementation: All therapeutic services and programmes provided by the approved centre were evidence-based and reflective of good practice guidelines. They were appropriate and met the assessed needs of the residents, as documented in the residents’ individual care plans. A list of therapeutic services and programmes provided within the approved centre was available to residents. All therapeutic services and programmes were directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of residents. Adequate resources and facilities were available. Therapeutic services and programmes were provided in separate dedicated rooms, and each ward had facilities to carry out group programmes or one to one sessions. A record was maintained of participation, engagement, and outcomes achieved in therapeutic services or programmes, within residents’ clinical files. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



Regulation 18: Transfer of Residents

(1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place.

(2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the transfer of residents, which was last reviewed in June 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for the transfer of residents, as set out in the policy. Monitoring: A log of transfers was maintained. Each transfer record had been systematically reviewed to ensure all relevant information was provided to the receiving facility. Documented analysis had been completed to identify opportunities for improving the provision of information during transfers. Evidence of Implementation: The clinical file of one resident who had been transferred from the approved centre was examined. This was a planned transfer and not an emergency transfer. Communication records with the receiving facility were documented, and their agreement to receive the resident in advance of the transfer was documented. This included the reasons for transfer, the resident’s care and treatment plan, including needs and risks, and the resident’s accompaniment requirements on transfer. The resident was risk assessed prior to the transfer, and this included an individual risk assessment relating to the transfer and the resident’s needs. Consent of the resident to the transfer was documented and available. The following information was issued, with copies retained as part of the transfer documentation: a letter of referral, including a list of current medications, and the resident transfer form. A checklist was completed by the approved centre to ensure comprehensive records were transferred to the receiving facility. Copies of all records relevant to the transfer process were retained in the residents’ clinical file. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



Regulation 19: General Health

(1) The registered proprietor shall ensure that:

(a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required;

(b) each resident's general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and;

(c) each resident has access to national screening programmes where available and applicable to the resident.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the provision of general health services and the response to medical emergencies, which was last reviewed in August 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to the provision of general health services and the response to medical emergencies, as set out in the policy. Monitoring: Residents’ take-up of national screening programmes was recorded and monitored, where applicable. A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis had been completed to identify opportunities for improving general health processes. Evidence of Implementation: The approved centre had opened approximately five months prior to the inspection and the six monthly general health assessments, and annual assessments of residents on antipsychotic medication had therefore not yet taken place. The approved centre had an emergency resuscitation trolley and staff had access at all times to an Automated External Defibrillator (AED). The emergency equipment was checked weekly. Records were available of any medical emergency within the approved centre and the care provided. Residents received appropriate general health care interventions in line with their individual care plans. Registered medical practitioners assessed residents’ general health needs at admission and when indicated by the residents’ specific needs. Residents’ general health needs were monitored and assessed as indicated by the residents’ specific needs, but not less than every six months. Adequate arrangements were in place for residents to access general health services and be referred to other health services, as required. Records were available demonstrating residents’ completed general health checks and associated results, including records of any clinical tests. Residents had access to national screening programmes appropriate to age and gender. Information was provided to all residents regarding the national screening programmes available. The approved centre policy on tobacco use indicated that it was a smoke free campus. Two units had been smoke free since the opening of the approved centre in June 2018. The approved centre had a fulltime



smoking cessation officer – a clinical nurse manager, with a masters in addiction. The smoking cessation service was also available to staff through pharmaceutical and one to one psychosocial interventions. The approved centre reported that the smoke free quality initiative was going well. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.


Regulation 20: Provision of Information to Residents

(1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language:

(a) details of the resident's multi-disciplinary team;

(b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements;

(c) verbal and written information on the resident's diagnosis and suitable written information relevant to the resident's diagnosis unless in the resident's psychiatrist's view the provision of such information might be prejudicial to the resident's physical or mental health, well-being or emotional condition;

(d) details of relevant advocacy and voluntary agencies;

(e) information on indications for use of all medications to be administered to the resident, including any possible side-effects.

(2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the provision of information to residents, which was last reviewed in March 2018. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the provision of information to residents, as set out in the policy. Monitoring: The provision of information to residents was monitored on an ongoing basis to ensure it was appropriate and accurate, particularly where information changed. Documented analysis had been completed to identify opportunities for improving the processes relating to the provision of information to residents. Evidence of Implementation: Residents were provided with an information booklet on admission that included details of meal times, personal property arrangements, the complaints procedure, visiting times and visiting arrangements, relevant advocacy and voluntary agencies details, and residents’ rights. The booklet was available in the required formats to support resident needs and the information was clearly and simply written. Residents were provided with details of their multi-disciplinary team (MDT). Residents were provided with written and verbal information on diagnosis. One doctor and the pharmacist met with groups of residents to discuss issues arising in relation to diagnosis and medications. The justification for restricting information regarding a resident’s diagnosis was documented in the clinical file. The information documents provided by or within the approved centre were evidence-based, and were appropriately reviewed and approved prior to use. Medication information sheets were available to residents, and staff could access the pharmacist when necessary. The pharmacist also ran groups with residents to discuss any issues arising with regard to diagnosis and medications.



The content of medication information sheets includes information on indications for use of all medications to be administered to the resident, including any possible side-effects. Residents had access to interpretation and translation services as required. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.


Regulation 21: Privacy

The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times.

INSPECTION FINDINGS Processes: The approved centre had a policy in relation to resident privacy, which was last reviewed in October 2017. The policy addressed all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed could articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: A documented annual review had been undertaken to ensure that the policy was being implemented and that the premises and facilities in the approved centre were conducive to resident privacy. Analysis had been completed to identify opportunities for improving the processes relating to residents’ privacy and dignity. Evidence of Implementation: The general behaviour of staff and the way in which staff spoke with residents was respectful. Staff were discreet when discussing the resident’s condition and treatment needs at the time of the inspection. Residents were dressed appropriately to ensure their privacy and dignity. All bathrooms, showers, toilets, and single bedrooms had locks on the inside of the door, but not in cases where there was an identified risk to a resident. The single en suite toilet doors did not have a lock. Doors with locks had an override function. Rooms were not overlooked by public areas. Observation panels on doors of treatment rooms and bedrooms were fitted with blinds, curtains, or opaque glass. The nurse’s office window was designed with a narrow gap in the surrounding glass and the glass was not opaque. The design increased the risk that residents or visitors in the nearby vicinity may overhear or observe confidential information. Noticeboards did not display any identifiable resident information; all noticeboards were covered with blinds. Residents were facilitated to make private phone calls. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



Regulation 22: Premises

(1) The registered proprietor shall ensure that:

(a) premises are clean and maintained in good structural and decorative condition;

(b) premises are adequately lit, heated and ventilated;

(c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained.

(2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre.

(3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors.

(4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice.

(5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities.

(6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000.

INSPECTION FINDINGS Processes: The approved centre did not have a written policy in relation to premises at the time of the inspection. Training and Education: There was no premises policy in place for staff to read at the time of the inspection. Relevant staff interviewed could articulate the processes relating to the maintenance of the premises. Monitoring: The approved centre had completed separate hygiene and ligature audits. Documented analysis had been completed to identify opportunities for improving the premises. Evidence Of Implementation: The approved centre was a new build and opened five months prior to this inspection. Access to each unit was via an electronic swipe card system. It was bright, spacious, and well lit. It was adequately lit, heated, and ventilated. The approved centre was registered for fifty beds. There were four units including Holly, Ash, Hazel, and Oak units. There was a sufficient number of toilets and showers for residents in the approved centre. All resident bedrooms were appropriately sized to address the resident needs. The majority of residents were accommodated in single en suite bedrooms. A small number of residents shared double or triple en suite dormitory bedrooms on Hazel and Ash units. The approved centre had a designated sluice room, a designated cleaning room, and a laundry room. Remote or isolated areas of the approved centre were monitored. Residents had access to sufficient space to move about freely in inside and outside of the approved centre. Each unit had direct access to a spacious enclosed garden or courtyard. Communal rooms were appropriately sized and were available on each unit. Appropriate signage and sensory aids were provided to support resident and visitors in finding their way around the building without confusion. Hazards were minimised throughout the approved



centre. Ligature point risks were not minimised however, the approved centre had a plan in place to remove these ligature points. At the time of inspection, the approved centre was engaged in active risk management to mitigate risk while awaiting ligature removal. The approved centre was kept in a good state of repair externally and internally. There was a programme of general maintenance, decorative maintenance, cleaning, decontamination, and repair of assistive equipment. There was a cleaning schedule, which was implemented. Where faults or problems were identified in relation to the premises, this was communicated through the appropriate maintenance reporting process. Current national infection control guidelines were followed. Backup power was available to the approved centre. Parking was limited throughout the whole University Hospital Galway campus. Illegal parking was identified as a potential risk in the event that emergency services required access to the building. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and evidence of implementation pillars.


Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines

(1) The registered proprietor shall ensure that an approved centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents.

(2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended).

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the ordering, storing, prescribing, and administration of medication, which was last reviewed in March 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all nursing, pharmacy, and medical staff had signed the signature log to indicate that they had read and understood the policy. All nursing, medical, and pharmacy staff interviewed could articulate the processes relating to the ordering, prescribing, storing, and administering of medicines, as set out in the policy. Staff had access to comprehensive, up-to-date information on all aspects of medication management. Nursing, medical, and pharmacy staff had received training on the importance of reporting medication incidents, errors, or near misses. Monitoring: Quarterly audits of Medication Prescription and Administration Records (MPARs) had been undertaken to determine compliance with the policies and procedures and the applicable legislation and guidelines. Incident reports were recorded for medication incidents, errors, and near misses. Analysis had been completed to identify opportunities for improving medication management processes. Evidence of Implementation: Each resident had an MPAR, ten of which were inspected. Each MPAR evidenced a record of appropriate medication management practices, including a record of two resident identifiers, records of all medications administered, and details of route, dosage, and frequency of medication. The Medical Council Registration Number of every medical practitioner prescribing medication to the resident was present within each resident’s MPAR. A record was kept when medication was refused by or withheld from the resident. In two MPARs micrograms were not written in full, instead abbreviations were used. All entries in the MPAR were legible, and written in black indelible ink. Medicinal products were administered in accordance with the directions of the prescriber. The expiration date of the medication was checked prior to administration; and expired medications were not administered.

All medicines, including scheduled controlled drugs were administered by a registered nurse or registered medical practitioner. Controlled drugs were checked by two staff members prior to administration. The use of appropriate resident identifiers, good hand-hygiene techniques, and cross-infection control techniques were observed during the administration of medication. Medication dispensed or supplied to the resident was stored securely in a locked storage unit, or fridge when appropriate. The medication administration cupboard remained locked at all times and secured in a locked room.



Medication was stored in the appropriate environment, as advised by the pharmacist. Refrigerators used for medication were used only for this purpose and a log was maintained of fridge temperatures. An inventory of medications was conducted on a monthly basis by the pharmacy, checking the name and dose of medication, quantity of medication, and expiry date. Medications that were no longer required, which were past their expiry date or had been dispensed to a resident but were no longer required were stored in a secure manner, segregated from other medication, and were returned to the pharmacy for disposal. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and evidence of implementation pillars.


Regulation 24: Health and Safety

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the health and safety of residents, staff and visitors.

(2) This regulation is without prejudice to the provisions of Health and Safety Act 1989, the Health and Safety at Work Act 2005 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a series of written operational policies and procedures in relation to the health and safety of residents, staff, and visitors. The health and safety policy was last reviewed in November 2018. The policy addressed all the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the health and safety policy. All staff interviewed were able to articulate the processes relating to health and safety, as set out in the policy. Monitoring: The health and safety policy was monitored pursuant to Regulation 29: Operational Policies and Procedures. Evidence of Implementation: Regulation 24 was only assessed against the approved centre’s written policies and procedures. Health and safety practices within the approved centre were not assessed. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 25: Use of Closed Circuit Television

(1) The registered proprietor shall ensure that in the event of the use of closed circuit television or other such monitoring device for resident observation the following conditions will apply:

(a) it shall be used solely for the purposes of observing a resident by a health

professional who is responsible for the welfare of that resident, and solely for the purposes of ensuring the health and welfare of that resident;

(b) it shall be clearly labelled and be evident;

(c) the approved centre shall have clear written policy and protocols articulating its function, in relation to the observation of a resident;

(d) it shall be incapable of recording or storing a resident's image on a tape, disc, hard drive, or in any other form and be incapable of transmitting images other than to the monitoring station being viewed by the health professional responsible for the health and welfare of the resident;

(e) it must not be used if a resident starts to act in a way which compromises his or her dignity.

(2) The registered proprietor shall ensure that the existence and usage of closed circuit television or other monitoring device is disclosed to the resident and/or his or her representative.

(3) The registered proprietor shall ensure that existence and usage of closed circuit television or other monitoring device is disclosed to the Inspector of Mental Health Services and/or Mental Health Commission during the inspection of the approved centre or at any time on request.

INSPECTION FINDINGS Processes: The approved centre had a written policy and protocols in relation to the use of CCTV, which was last reviewed in April 2018. The policy included the requirements of the Judgement Support Framework with the following exceptions:

The maintenance of CCTV cameras by the approved centre.

The process to cease monitoring a resident using CCTV in certain circumstances. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to the use of CCTV, as set out in the policy. Monitoring: The CCTV equipment was checked regularly to ensure that the equipment was operating appropriately. Analysis had been completed to identify opportunities for improving the processes relating to the use of CCTV. Evidence of Implementation: There were clear signs in prominent positions where CCTV cameras were located throughout the approved centre. CCTV was used solely for the purposes of observing a resident by a health professional who was responsible for the welfare of that resident. CCTV cameras used to observe residents were capable of recording or storing a resident’s image. There was electronic e-mail evidence to indicate that CCTV cameras were capable of recording, and that CCTV cameras were in need of setting adjustment to have the setting changed to non-recording. CCTV cameras used to observe residents did not transmit images other than to a monitor that was viewed solely by the health professional responsible for the resident. CCTV was not used to monitor a resident if they started to act in a way that compromised their dignity. The Mental Health Commission had been informed about the approved centre’s use of CCTV.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


The approved centre was non-compliant with this regulation because the CCTV used for resident observation was capable of recording resident images, 22, (1d).


Regulation 26: Staffing

(1) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the recruitment, selection and vetting of staff.

(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the approved centre.

(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the approved centre at all times and a record thereof maintained in the approved centre.

(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice.

(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role.

(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to its staffing requirements. The staffing policy was last reviewed in March 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to staffing, as set out in the policy. Monitoring: The approved centre was a new service, which opened in June 2018 (five months prior to this inspection) and it was too early for an annual review of the training plan. The numbers and skill mix of staff had been reviewed against the levels recorded in the approved centre’s registration. Analysis had been completed to identify opportunities to improve staffing processes and respond to the changing needs and circumstances of residents. Evidence of Implementation: The organisational chart in place identified the leadership and management structure and the lines of authority and accountability of the approved centre’s staff. Staff were recruited and selected in accordance with the approved centre’s policy and procedures for recruitment, selection, and appointment. Staff within the approved centre had the appropriate qualifications, skills, knowledge, and experience to do their jobs. A planned and actual staff rota, showing the staff on duty at any one time during the day and night, was maintained in the approved centre. An appropriately qualified staff member was on duty and in charge at all times. Opportunities were made available to staff by the approved centre for further education. These opportunities were e-mailed to staff frequently. The number and skill mix of staffing were sufficient to meet resident needs. A written staffing plan was not available within the approved centre. Staff received training in manual handling; however, there was no evidence of staff training in the areas of risk management, incident reporting, and dementia care. Not all health care staff were trained in the following:



Fire safety

Basic Life Support

The Professional Management of Violence and Aggression (PMAV)

The Mental Health Act 2001

Children First

All staff training was documented and staff training logs were maintained. The Mental Health Act 2001, and Mental Health Commission Rules and Codes, and all other relevant Mental Health Commission documentation and guidance was made available to staff throughout the approved centre. The following is a table of clinical staff assigned to the approved centre.

There was a resident Occupational Therapy service within the approved centre. The service consisted of one senior and one junior therapist and one occupational therapy assistant. Therapy was provided across all four Suites.

The discipline of Psychology and Social Work was provided by in-reach services and on referral basis only.

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Health Care Assistant (HCA).

The approved centre was non-compliant with this regulation for the following reasons:

Ward or Unit Staff Grade Day Night

Oak Suite

CNM3 CNM2 RPN

1 1 3

0 1 2


Ash Suite

CNM3 CNM2 RPN HCA

0 1 3 1

1 0 3 0


Hazel Suite

CNM2 RPN

1 4

0 3


Holly Suite

CNM2 RPN HCA

1 2 1

0 2 1


a) Not all staff had up-to-date mandatory training in Basic Life Support, fire safety, and the

Professional Management of Violence and Aggression, 26(4). b) Not all staff had up-to-date mandatory training in the Mental Health Act 2001, 26(5).


Regulation 27: Maintenance of Records

(1) The registered proprietor shall ensure that records and reports shall be maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. All records shall be kept up-to-date and in good order in a safe and secure place.

(2) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the creation of, access to, retention of and destruction of records.

(3) The registered proprietor shall ensure that all documentation of inspections relating to food safety, health and safety and fire inspections is maintained in the approved centre.

(4) This Regulation is without prejudice to the provisions of the Data Protection Acts 1988 and 2003 and the Freedom of Information Acts 1997 and 2003.

Note: Actual assessment of food safety, health and safety and fire risk records is outside the scope of this Regulation, which refers only to maintenance of records pertaining to these areas.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the maintenance of records, which was last reviewed in March 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff and other relevant staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff and other relevant staff interviewed were able to articulate the processes relating to the creation of, access to, retention of, and destruction of records, as set out in the policy. All clinical staff were trained in best-practice record keeping. Monitoring: Resident records were audited to ensure their completeness, accuracy, and ease of retrieval. The records of transferred and discharged residents were included in the review process insofar as was practicable. Analysis had been completed to identify opportunities to improve the processes relating to the maintenance of records. Evidence of Implementation: Residents’ records were appropriately secured throughout the approved centre from loss, destruction, tampering, or unauthorised access or use. A number of clinical files were inspected. Resident records were reflective of the residents’ status at the time of inspection and the care and treatment being provided. Clinical files inspected were not in good order; a number of the clinical files inspected contained loose pages. Resident records were not developed and maintained in a logical sequence, and medical continuation notes were out of sequence and filed in a separate section of the clinical file. Resident records were physically stored together. Resident records were maintained using an identifier, which was unique to the resident. While each record had one resident identifier, a number of clinical files did not contain two resident identifiers. Only authorised staff made entries in residents’ records, or specific sections therein. Hand-written records were legible, written in black indelible ink, and were readable when photocopied. Not all residents’ records included the factually correct admission date; in one case, the resident’s record contained numerous differing dates for ‘date of admission’. Documentation relating to food safety, health and safety, and fire inspections were maintained in the approved centre.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW


The approved centre was non-compliant with this regulation because records were not maintained in a manner so as to ensure completeness, accuracy, and ease of retrieval due to the following:

a) Resident records contained loose pages, 27 (1). b) Resident records were not developed and maintained in a logical sequence, and medical

continuation notes were out of sequence and filed in a separate section of the clinical file, 27 (1).

c) Two resident identifiers were not recorded on all documentation, 27(1). d) One resident record contained multiple differing dates of admission, 27(1).


Regulation 28: Register of Residents

(1) The registered proprietor shall ensure that an up-to-date register shall be established and maintained in relation to every resident in an approved centre in a format determined by the Commission and shall make available such information to the Commission as and when requested by the Commission.

(2) The registered proprietor shall ensure that the register includes the information specified in Schedule 1 to these Regulations.

INSPECTION FINDINGS The approved centre had a documented register of residents admitted. The register did not contain all of the required information specified in Schedule 1 to the Mental Health Act 2001 (Approved Centres) Regulations 2006. Diagnosis on admission or provisional diagnosis on admission were not documented. Diagnosis on discharge was not recorded. Resident names were not consistently recorded, which meant the register of residents was not up-to-date.

The approved centre was non-compliant with this regulation for the following reasons:

a) The register was not up-to-date, residents names were not consistently recorded, 28 (1). b) The register did not include all of the information specified in Schedule 1 of these Regulations,

28 (2).



Regulation 29: Operating Policies and Procedures

The registered proprietor shall ensure that all written operational policies and procedures of an approved centre are reviewed on the recommendation of the Inspector or the Commission and at least every 3 years having due regard to any recommendations made by the Inspector or the Commission.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development and review of operating policies and procedures required by the regulations, which was last reviewed in June 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Not all relevant staff had been trained on approved operational policies and procedures. Relevant staff interviewed could articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit had been undertaken to determine compliance with review timeframes. Analysis had been completed to identify opportunities for improving the processes of developing and reviewing the policy. Evidence of Implementation: A policy and procedure group was responsible for the development and review of policies in the approved centre. The approved centre’s operating policies and procedures were developed with input from clinical and managerial staff and in consultation with relevant stakeholders, including service-users, as appropriate. Operating policies and procedures were communicated to all relevant staff. The operating policies and procedures required by the regulations were all reviewed within the required three-year timeframe, were appropriately approved, and incorporated relevant legislation, evidence-based best practice and clinical guidelines. The format of the operating policies and procedures was standardised. Obsolete versions of operating policies and procedures were retained but removed from possible access by staff. Where generic policies were used, the approved centre had a written statement to this effect adopting the generic policy, which was reviewed at least every three years. The approved centre was compliant with this regulation. The quality assessment was satisfactory and

not rated excellent, as the approved centre did not meet all criteria of the Judgement Support

Framework under the training and education pillar.



Regulation 30: Mental Health Tribunals

(1) The registered proprietor shall ensure that an approved centre will co-operate fully with Mental Health Tribunals.

(2) In circumstances where a patient's condition is such that he or she requires assistance from staff of the approved centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the facilitation of Mental Health Tribunals, which was last reviewed in March 2017. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes for facilitating Mental Health Tribunals, as set out in the policy. Monitoring: Analysis had been completed to identify opportunities for improving the processes for facilitating Mental Health Tribunals. Evidence of Implementation: The approved centre provided private facilities and adequate resources to support the Mental Health Tribunal process. It had a bright and spacious Tribunal room, with a large table and chairs. There were offices which legal representatives could book and use for tribunal related work. Staff accompanied and assisted patients to attend their Mental Health Tribunals as necessary. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 31: Complaints Procedures

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the making, handling and investigating complaints from any person about any aspects of service, care and treatment provided in, or on behalf of an approved centre.

(2) The registered proprietor shall ensure that each resident is made aware of the complaints procedure as soon as is practicable after admission.

(3) The registered proprietor shall ensure that the complaints procedure is displayed in a prominent position in the approved centre.

(4) The registered proprietor shall ensure that a nominated person is available in an approved centre to deal with all complaints.

(5) The registered proprietor shall ensure that all complaints are investigated promptly.

(6) The registered proprietor shall ensure that the nominated person maintains a record of all complaints relating to the approved centre.

(7) The registered proprietor shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident's individual care plan.

(8) The registered proprietor shall ensure that any resident who has made a complaint is not adversely affected by reason of the complaint having been made.

(9) This Regulation is without prejudice to Part 9 of the Health Act 2004 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in place in relation to the management of complaints, which was last reviewed in October 2018. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the process for managing complaints, the raising, handling, and investigation of complaints from any person regarding any aspect of the services, care, and treatment provided in or on behalf of the approved centre. Training and Education: Not all relevant staff had been trained on the complaints management process. Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes for making, handling, and investigating complaints, as set out in the policy. Monitoring: As the approved centre had recently opened at the time of the inspection, audit of the complaints records and analysis of complaints data was deemed not applicable. Evidence of Implementation: There were two nominated staff members responsible for dealing with all complaints available and based in the approved centre. The assistant director of nursing was the complaints officer who was responsible for minor complaints and for complaints escalation. The business manager was the nominated person responsible for dealing with major complaints. A consistent and standardised approach had been implemented for the management of all complaints. The complaints procedure, including how to contact the nominated person was publicly displayed on the noticeboard, and it was detailed within the resident’s information booklet. Residents, their representatives, family, and next of kin were informed of all methods by which a complaint could be made through noticeboards and information booklets. Complaints could be lodged verbally, in writing, electronically through e-mail, by telephone, and through complaint, feedback, or suggestion forms.

COMPLIANT


All complaints were handled promptly, appropriately and sensitively. Where complaints could not be addressed by the nominated person, they were escalated in accordance with the approved centre’s policy. This was documented in the complaints log. The quality of the service, care and treatment of a resident did not appear to be adversely affected by reason of the complaint being made at the inspection time. All complaints were dealt with by the nominated person and recorded in the complaints log. Minor complaints were documented separately to other complaints. Where minor complaints could not be addressed locally, the nominated person dealt with the complaint. The complainant was informed promptly of the outcome of the complaint investigation and details of the appeals process made available to them. All information obtained through the course of the management of the complaint and the associated investigation process was treated in a confidential manner and met the requirements of the Data Protection Acts 1988 and 2003 and the Freedom of Information Act 1997 and 2003. Details of complaints, as well as subsequent investigations and outcomes, were fully recorded and kept distinct from the resident’s individual care plan. The complainant’s satisfaction or dissatisfaction with the investigation findings was documented. The approved centre was compliant with this regulation. As all requirements of the monitoring pillar

were deemed not applicable, Regulation 31: Complaints Procedures was only assessed under the three

pillars of processes, training and education and evidence of implementation.


Regulation 32: Risk Management Procedures

(1) The registered proprietor shall ensure that an approved centre has a comprehensive written risk management policy in place and that it is implemented throughout the approved centre.

(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:

(a) The identification and assessment of risks throughout the approved centre;

(b) The precautions in place to control the risks identified;

(c) The precautions in place to control the following specified risks:

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

(f) Arrangements for the protection of children and vulnerable adults from abuse.

(3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a series of written policies in relation to risk management and incident management procedures, which was last reviewed in March 2018. The policy addressed all of the requirements of the Judgement Support Framework, including the following:

The process for identification, assessment, treatment, reporting, and monitoring of risks throughout the approved centre.

The process for rating identified risks.

The methods for controlling risks associated with resident absence without leave, suicide and self-harm, assault, and accidental injury to residents or staff.

The process for managing incidents involving residents of the approved centre.

The process for protecting children and vulnerable adults in the care of the approved centre. Training and Education: Relevant staff had received training in the identification, assessment, and management of risk and in health and safety risk management. Clinical staff were not trained in individual risk management processes. Management were trained in organisational risk management. All training was documented. Not all staff had been trained in incident reporting and documentation. Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the risk management processes, as set out in the policy. Monitoring: The risk register was reviewed at least quarterly to determine compliance with the approved centre’s risk management policy. Analysis of incident reports had been completed to identify opportunities for improving risk management processes. Evidence of Implementation: The person with responsibility for risk, the risk advisor, was identified and known by all staff, and responsibilities were allocated at management level and throughout the approved centre to ensure their effective implementation. Risk management procedures actively reduced identified



risks to the lowest level of risk, as was reasonably practicable. Multi-disciplinary teams were involved in the development, implementation, and review of individual risk management processes. Clinical, health and safety risks were identified, assessed, reported, treated, monitored, and recorded in the risk register. Individual risk assessments were completed prior to episodes of physical restraint and seclusion, specialised treatments including electro-convulsive therapy, and at resident admission and transfer. These assessments were completed in conjunction with medication requirements or medication administration, with the aim of identifying individual risk factors. Structural risks, including ligature points, remained however; the approved centre had a plan in place to remove these ligature points. At the time of inspection, the approved centre was engaged in active risk management to mitigate risk while awaiting ligature removal. The requirements for the protection of children and vulnerable adults within the approved centre were appropriate and implemented as required. Incidents were risk-rated in a standardised format, and were recorded on the National Incident Management System. All clinical incidents were reviewed weekly by the multi-disciplinary team. A record was maintained of this review and recommended actions. The risk advisor and the clinical nurse manager reviewed incidents for any trends or patterns occurring in the service. A six-monthly summary of incidents was provided to the Mental Health Commission by the Mental Health Act administrator. Information provided was anonymous at resident level. There was an emergency plan in place that specified responses by the approved centre staff in relation to possible emergencies. The emergency plan incorporated evacuation procedures. The approved centre was compliant with this regulation. The quality assessment was satisfactory and

not rated excellent, as the approved centre did not meet all criteria of the Judgement Support

Framework under the training and education pillar.


Regulation 33: Insurance

The registered proprietor of an approved centre shall ensure that the unit is adequately insured against accidents or injury to residents.

INSPECTION FINDINGS The approved centre’s insurance certificate was provided to the inspection team. It confirmed that the approved centre was covered by the State Claims Agency for public liability, employer’s liability, clinical indemnity, and property. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 34: Certificate of Registration

The registered proprietor shall ensure that the approved centre's current certificate of registration issued pursuant to Section 64(3)(c) of the Act is displayed in a prominent position in the approved centre.

INSPECTION FINDINGS The approved centre had an up-to-date certificate of registration. The certificate was displayed prominently in the reception area of the approved centre. The approved centre was compliant with this regulation.

COMPLIANT


9.0 Inspection Findings – Rules

EVIDENCE OF COMPLIANCE WITH RULES UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)


Section 59: The Use of Electro-Convulsive Therapy

Section 59 (1) A programme of electro-convulsive therapy shall not be administered to a patient unless either – (a) the patient gives his or her consent in writing to the administration of the programme of therapy, or (b) where the patient is unable to give such consent – (i) the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient, and (ii) the programme of therapy is also authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist. (2) The Commission shall make rules providing for the use of electro-convulsive therapy and a programme of electro-convulsive therapy shall not be administered to a patient except in accordance with such rules.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the use of Electro-Convulsive Therapy (ECT) for involuntary patients, which was last reviewed in November 2018. The policy addressed all policy-related criteria of this rule, including ECT protocols developed in line with best international practice, including:

How and where the initial and subsequent doses of Dantrolene are stored.

Management of cardiac arrest.

Management of anaphylaxis.

Management of malignant hyperthermia. Training and Education: All staff involved in delivering ECT were trained in line with best international practice and had appropriate training and education in Basic Life Support techniques.

Evidence of Implementation: One patient was receiving ECT during the time of the inspection. The approved centre had a dedicated suite for the delivery of ECT, including a private waiting room and adequately equipped treatment and recovery rooms. A named consultant psychiatrist and anaesthetist had overall responsibility for ECT management and anaesthesia. There were at least two registered nurses on duty in the ECT suite at all times, one of whom was a designated ECT nurse. Materials and equipment in the ECT suite were in line with best international practice. Up-to-date protocols for the management of cardiac arrest, anaphylaxis, and malignant hyperthermia, were prominently displayed. There was a facility for monitoring electroencephalogram (EEG) on two channels. ECT machines were regularly maintained and serviced and this was documented. The file of one patient who received ECT was reviewed. The patient was assessed as being unable to consent to receiving a treatment of ECT, and this was recorded in the patient’s clinical file. Appropriate ECT information was given to the resident. ECT was administered according to section 59(1)(b) of MHA 2001, as amended. Two consultant psychiatrists assessed and recorded how ECT would benefit the patient, the views of the patient, and the patient’s ability to consent. The responsible consultant psychiatrist prescribed ECT and recorded the prescription. A Form 16: Electroconvulsive Therapy Involuntary Patient (Adult) – Unable to Consent was completed by both consultant psychiatrists for each ECT programme. The form was placed in the clinical file and a copy was sent to the Mental Health Commission within five days.

COMPLIANT


The anaesthesia and ECT were prescribed and administered. A record of the ECT administered was fully completed after one ECT treatment session. The patients’ clinical status was assessed before and after each ECT treatment session. There was ongoing monitoring of the patient’s cognitive functioning throughout the ECT programme. In line with best international practice, cognitive assessment was completed after each ECT programme. The consultant psychiatrist, in consultation with the patient, reviewed the continued use of ECT. Copies of all cognitive assessments were placed in the clinical file.

The approved centre was compliant with this rule.


Section 69: The Use of Seclusion

Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes –

(a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient.

INSPECTION FINDINGS Processes: There was a written policy in relation to the use of seclusion, and the policy was reviewed annually. It was last reviewed in February 2018. The policy included all of the guidance criteria of this rule pursuant to Section 69 of the Mental Health Act 2001. The policy included details of who may implement seclusion, the provision of information to the resident on the use of seclusion, and the ways of reducing rates of seclusion use. Training and Education: There was no written record to indicate that staff involved in seclusion had read and understood the policy. Monitoring: The approved centre opened as a new service, five months prior to this inspection and it was too early to complete an annual report. Evidence of Implementation: Residents in seclusion had access to adequate toilet and washing facilities. The seclusion room was clean and it was designed with furniture and fittings, which did not endanger resident safety. The seclusion room was not used as a bedroom. Seclusion was initiated by a registered nurse or registered medical practitioner. The consultant psychiatrist was notified within the appropriate time frame and this was recorded in the clinical file. The clinical files of two residents who had been in seclusion were inspected. One resident was secluded twice and one resident was secluded once, since the last inspection. Three seclusion episodes were reviewed. In all episodes, seclusion was only implemented in the resident’s best interests, in rare and exceptional circumstances where the resident posed an immediate and serious harm to self or others. Cultural awareness and gender sensitivity were demonstrated. Each resident was under direct observation by a registered nurse for the first hour and continuous observation thereafter. The following was evidenced on inspection:

NON-COMPLIANT Risk Rating


In two seclusion episodes, the resident was not informed of the reasons, duration, and circumstances leading to discontinuation of seclusion. The explanation for not telling the resident was not documented in the clinical files.

In two seclusion episodes, the resident was not informed of the ending of an episode of seclusion.

In one seclusion episode, the reason for ending seclusion was not recorded in the clinical file. All uses of seclusion were clearly recorded in clinical files and on the seclusion register. Each episode of seclusion was reviewed by members of the multi-disciplinary team and documented in the clinical file within two working days. The approved centre was non-compliant with this rule for the following reasons:

a) Not all staff involved in physical restraint had signed the policy log to indicate that they had read and understood the policy, 10.2(b).

b) In two seclusion episodes, the resident was not informed of the reasons, duration, and circumstances leading to discontinuation of seclusion. The explanation for not telling the resident was not documented in the clinical files, 3.6.

c) In two seclusion episodes, the resident was not informed of the ending of an episode of seclusion, 7.3.

d) In one seclusion episode, the reason for ending seclusion was not recorded in the clinical file, 7.4.


10.0 Inspection Findings – Mental Health Act 2001

EVIDENCE OF COMPLIANCE WITH PART 4 OF THE MENTAL HEALTH ACT 2001


Part 4 Consent to Treatment

56.- In this Part “consent”, in relation to a patient, means consent obtained freely without threat or inducements, where – a) the consultant psychiatrist responsible for the care and treatment of the patient is satisfied that the patient is

capable of understanding the nature, purpose and likely effects of the proposed treatment; and b) The consultant psychiatrist has given the patient adequate information, in a form and language that the patient can

understand, on the nature, purpose and likely effects of the proposed treatment. 57. - (1) The consent of a patient shall be required for treatment except where, in the opinion of the consultant psychiatrist responsible for the care and treatment of the patient, the treatment is necessary to safeguard the life of the patient, to restore his or her health, to alleviate his or her condition, or to relieve his or her suffering, and by reason of his or her mental disorder the patient concerned is incapable of giving such consent.

(2) This section shall not apply to the treatment specified in section 58, 59 or 60. 60. – Where medicine has been administered to a patient for the purpose of ameliorating his or her mental disorder for a continuous period of 3 months, the administration of that medicine shall not be continued unless either-

a) the patient gives his or her consent in writing to the continued administration of that medicine, or b) where the patient is unable to give such consent –

i. the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the patient, and

ii. the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent, or as the case may be, approval and authorisation shall be valid for a period of three months and thereafter for periods of 3 months, if in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained. 61. – Where medicine has been administered to a child in respect of whom an order under section 25 is in force for the purposes of ameliorating his or her mental disorder for a continuous period of 3 months, the administration shall not be continued unless either –

a) the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the child, and

b) the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist, following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent or, as the case may be, approval and authorisation shall be valid for a period of 3 months and thereafter for periods of 3 months, if, in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained.

INSPECTION FINDINGS The clinical files of ten patients who had been in the approved centre for more than three months and who had been in continuous receipt of medication were examined. In all ten cases, there was documented evidence that the consultant psychiatrist had undertaken a capacity assessment, which measured the patients’ ability to consent to receiving treatment. Following the capacity assessment, nine patients were deemed unable to consent to receiving treatment and one patient was deemed able to consent to receiving treatment. In relation to the patient who was assessed as having capacity and consented to receiving treatment, there was a written record of consent which detailed:

The names of the medications prescribed.

Confirmation of the assessment of the patient’s ability to understand the nature, purpose, and likely effects of the medications.

Details of discussions with the patient, including

The nature and purpose of the medications.

COMPLIANT


The effects of the medications(s), including any risks and benefits. In relation to the nine patients who lacked capacity and were unable to consent to receiving treatment, a Form 17: Administration of Medicine for More Than 3 Months Involuntary Patient (Adult) – Unable to Consent had been appropriately completed for all nine patients. Each form had:

The names of the medication prescribed.

Confirmation of the assessment of the patient’s ability to understand the nature, purpose, and likely effects of the medications.

Details of discussions with the patient, including:

The nature and purpose of the medications.

The effects of the medications, including any risks and benefits.

Any views expressed by the patient.

Supports provided to the patient in relation to the discussion and their decision-making.

Authorisation by a second consultant psychiatrist.

All forms were completed within the appropriate timeframe. The approved centre was compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment.


11.0 Inspection Findings – Codes of Practice

EVIDENCE OF COMPLIANCE WITH CODES OF PRACTICE – MENTAL HEALTH ACT 2001 SECTION 51 (iii)

Section 33(3)(e) of the Mental Health Act 2001 requires the Commission to: “prepare and review periodically, after consultation with such bodies as it considers appropriate, a code or codes of practice for the guidance of persons working in the mental health services”. The Mental Health Act, 2001 (“the Act”) does not impose a legal duty on persons working in the mental health services to comply with codes of practice, except where a legal provision from primary legislation, regulations or rules is directly referred to in the code. Best practice however requires that codes of practice be followed to ensure that the Act is implemented consistently by persons working in the mental health services. A failure to implement or follow this Code could be referred to during the course of legal proceedings. Please refer to the Mental Health Commission Codes of Practice, for further guidance for compliance in relation to each code.


Use of Physical Restraint

Please refer to the Mental Health Commission Code of Practice on the Use of Physical Restraint in Approved Centres, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: There was a written policy in relation to the use of physical restraint. The policy was reviewed annually, and it was last reviewed in March 2018. The policy addressed all of the policy-related relevant items of this code of practice, including the provision of information to the resident, those who can initiate and who may implement physical restraint, and the child protection process where a child is physically restrained. Training and Education: Not all staff involved in physical restraint had signed the policy log to indicate that they had read and understood the policy. Monitoring: The approved centre opened as a new service, five months prior to this inspection and it was too early to complete an annual report on the use of physical restraint. Evidence of Implementation: The clinical files of three residents who had been physically restrained were inspected. In all cases, physical restraint was initiated by an appropriately qualified health professional. Physical restraint was used in rare and exceptional circumstances only when the resident posed an immediate threat of serious harm to themselves or others. Cultural awareness and gender sensitivity were demonstrated when considering the use of and when using physical restraint. In all cases, the clinical practice form was signed by the consultant psychiatrist within 24 hours, and the completed clinical practice form was placed in the resident’s clinical file. The following was found on inspection:

In two cases, there was no record to indicate that the resident had received a medical exam at all by a registered medical practitioner, within three hours after the start of an episode of physical restraint. In one case, while a medical exam did take place there was no time recorded to show that the exam took place within three hours after the start of the physical restraint episode.

In two physical restraint episodes, residents were not informed of the reasons for, duration of, and circumstances leading to discontinuation of physical restraint. The reasons for not informing them was not documented in either case.

In two episodes of physical restraint the resident’s next of kin was not informed about the physical restraint and the reasons for not informing them was not documented in two cases.

In all three physical restraint episodes, there was no documented record to indicate that each episode of physical restraint was reviewed by members of the multi-disciplinary team and documented in the clinical file within two working days after the episode.

The approved centre was non-compliant with this code of practice for the following reasons:

a) Not all staff involved in physical restraint had signed the policy log to indicate that they had read and understood the policy, 9.2 (b).

b) In two cases, there was no record to indicate that the resident had received a medical exam at all by a registered medical practitioner, within three hours after the start of an episode of



physical restraint by a registered medical practitioner. In one cases, while a medical exam did take place there was no time record to show that it took place within three hours after the start of the physical restraint episodes, 5.4.

c) In two physical restraint episodes, residents were not informed of the reasons for, duration of, and circumstances leading to discontinuation of physical restraint. The reasons for not informing them was not documented in either case, 5.8.

d) In two episodes of physical restraint the resident’s next of kin was not informed about the physical restraint and the reasons for not informing them was not documented in two cases, 5.9 (a).

e) In all three physical restraint episodes, there was no documented record to indicate that each episode of physical restraint was reviewed by members of the multi-disciplinary team and documented in the clinical file within two working days after the episode, 9.3.


Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients

Please refer to the Mental Health Commission Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the use of Electro-Convulsive Therapy (ECT) for voluntary patients. It was last reviewed in November 2018. The policy addressed all of the policy-related criteria of this rule, and it detailed ECT protocols developed in line with best international practice, which addressed:

How and where the initial and subsequent doses of Dantrolene were stored.

Management of cardiac arrest.

Management of anaphylaxis.

Management of malignant hyperthermia. Training and Education: All staff involved in delivering ECT were trained in line with best international practice and had appropriate training and education in Basic Life Support techniques. Evidence of Implementation: The approved centre had a dedicated ECT suite for the delivery of ECT. The ECT suite had a private waiting room and adequately equipped treatment and recovery rooms. High-risk residents were treated in a rapid-intervention area. Material and equipment for ECT, including emergency drugs, were in line with best international practice. ECT machines were regularly maintained and serviced, and this was documented. Up-to-date protocols for the management of cardiac arrest, anaphylaxis, and hyperthermia were prominently displayed. A named consultant psychiatrist had responsibility for ECT management, and a named consultant anaesthetist had overall responsibility for anaesthesia. At least two registered nurses were in the ECT suite at all times, one of whom was a designated ECT nurse. The clinical file of one voluntary resident who was receiving ECT were examined. The consultant psychiatrist assessed the resident’s capacity to consent to receiving treatment, and this was documented in the resident’s clinical file. The resident was deemed capable of consenting to receiving ECT. Appropriate information on ECT was given by the consultant psychiatrist to enable the resident to make a decision on consent. Information was provided on the likely adverse effects of ECT, including the risk of cognitive impairment and amnesia and other potential side effects. Information was provided both orally and in writing, in a clear and simple language that the resident could understand. The resident was informed of his/her rights to an advocate and had the opportunity to raise questions at any time. Consent was obtained in writing for each ECT treatment session, including anaesthesia. The consultant psychiatrist administered a capacity assessment on the resident. A programme of ECT for the resident was prescribed by the responsible consultant psychiatrist and recorded in the clinical file. The prescription detailed the reason for using ECT, the consideration of alternative therapies that proved ineffective before prescribing ECT, the discussion with the resident and their next of kin, a current mental state examination, and the assessments completed before and after each ECT treatment. A pre-anaesthetic assessment was documented in the clinical file, and an anaesthetic risk assessment was recorded. ECT was administered by a constant current, brief pulse ECT machine.

COMPLIANT


The ECT record which was completed after each treatment was placed in the clinical file, and the signature of the registered medical practitioner administering ECT was detailed. All pre and post ECT assessments were detailed and recorded in the clinical file. The reasons for continuing or discontinuing ECT was recorded. Copies of all cognitive assessments were placed in the clinical file. The approved centre was compliant with this code of practice.


Admission, Transfer and Discharge

Please refer to the Mental Health Commission Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had separate written policies in relation to admission, transfer, and discharge. The admission policy was last reviewed in October 2016 the transfer policy in June 2017, and the discharge policy in March 2018. All policies combined included all of the policy-related criteria of the code of practice. Training and Education: There was no documentary evidence of staff signatures to indicate that all relevant staff had read and understood the admission, transfer, and discharge policies. Monitoring: The approved centre opened in June 2018, five months prior to this inspection and it was too early for the approved centre’s audits of their policies to have taken place. Evidence of Implementation: Admission: The clinical file of one resident was inspected in relation to the admission process. Their admission was on the basis of a mental illness or mental disorder. The resident received an admission assessment, which included presenting problem, past psychiatric history, family history, medical history, current and historic medication, current mental state, a risk assessment, and any other relevant information such as work situation, education, and dietary requirements. The resident received a full physical examination. Transfer: The approved centre complied with Regulation 18: Transfer of Residents. Discharge: The clinical file of one resident who was discharged was inspected. The discharge was co-ordinated by a key-worker. A discharge plan was in place as part of the individual care plan. A discharge meeting was held and attended by the resident and their key worker, relevant members of the multi-disciplinary team (MDT) and the resident’s family. A pre-discharge assessment was completed which addressed the resident’s psychiatric and psychological needs, a current mental state examination, informational needs, social and housing needs, and a comprehensive risk assessment and risk management plan. Family members were involved in the discharge process. There was appropriate MDT input into discharge planning. The following was found on inspection:

The discharge plan did not include documented communication with the relevant general practitioner.

The preliminary discharge summary was not sent to the general practitioner within three days.

A comprehensive discharge summary was not issued to relevant personnel within the required timeframe of 14 days, instead it was sent 23 days after the resident had been discharged.

Discharge summaries did not include details of prognosis.

A timely follow up appointment specific to the needs of the resident who was discharged was not arranged or detailed; instead, an untimely late appointment was recorded in the resident’s file.



The approved centre was non-compliant with this code of practice for the following reasons:

a) The approved centre was non-compliant with this code of practice because there was no documentary evidence that all relevant staff had read and understood the admission, transfer, and discharge policies, 9.1.

b) The discharge plan did not include documented communication with the relevant general practitioner, 34.2.

c) The preliminary discharge summary was not sent to the general practitioner within three days, 38.3.

d) A comprehensive discharge summary was not issued to relevant personnel within the required timeframe of 14 days, instead it was sent 23 days after the resident had been discharged, 38.3 (b).

e) Discharge summaries did not include details of prognosis, 38.4. f) A timely follow up appointment, specific to the needs of the resident, was not arranged within

one week post discharge from the approved centre, 41.1 (c).

Appendix 1: Corrective and Preventative Action Plan Template – AAMHU Galway - 2018 Inspection Report

Regulation 25: Use of Closed Circuit Television Report reference: Pages 43 & 44

Area(s) of non-compliance Specific Measureable Achievable / Realistic Time-bound

1. The CCTV used for resident

observation was capable of

recording resident images, 22,

(1d).

New

Corrective Action(s): System is no longer

capable of recording.

Post-Holder(s) responsible: Registered

Proprietor

CCTV system is checked

monthly to ensure it not

recording.

Achievable and realistic. Immediate.

Preventative Action(s): Controlled access to

CCTV system in place.

Post-Holder(s) responsible: Registered

Proprietor

As above. As above. As above.

Regulation 26: Staffing Report reference: Pages 45, 46 & 47


2. Not all staff had up-to-date

mandatory training in Basic Life

Support, fire safety, and the

Professional Management of

Violence and Aggression, 26(4).

3. Not all staff had up-to-date

mandatory training in the

Mental Health Act 2001, 26(5).

New

Corrective Action(s): Heads of Disciplines to

ensure relevant staff complete mandatory

training.

Post-Holder(s) responsible: Heads of

Discipline.

Certificates of completion

to be collated and

available to Inspectors.

Achievable. 6 months.

Preventative Action(s): Regular training needs

analysis to identify training deficits

and schedule of training circulated to staff.


discipline.

Same as above. Achievable. 6 months.

Regulation 27: Maintenance of Records Report reference: Pages 48 & 49


4. Resident records contained

loose pages, 27 (1).

5. Resident records were not

developed and maintained in a

logical sequence, and medical

continuation notes were out of

sequence and filed in a separate

section of the clinical file, 27 (1).

New

Corrective Action(s): Memo issued to all

disciplines by Clinical Director directing staff

to file clinical notes in keeping with

regulations 27.

Post-Holder(s) responsible: All Staff.

Audits of records to be

undertaken every 3

months.

Achievable. Ongoing.

Preventative Action(s): Ongoing monitoring of

records in keeping with audit cycle.

Post-Holder(s) responsible: CNM 3.

As above. Achievable. Ongoing.

6. Two resident identifiers were

not recorded on all

documentation, 27(1).

7. One resident record contained

multiple differing dates of

admission, 27(1).

New

Corrective Action(s): Memo sent to all staff

reminding them to use two resident

identifiers on all documentation.

Post-Holder(s) responsible: All staff.


Preventative Action(s): Memo sent to all staff

to ensure appropriate dates are recorded on

all documentation.



Regulation 28: Register of Residents Report reference: Page 50


8. The register was not up-to-date,

residents names were not

consistently recorded, 28 (1).

New

Corrective Action(s): Register of resident’s

policy being reviewed and updated.

Post-Holder(s) responsible: Regional Practice

Development Coordinator.

3 monthly audit. Achievable. Ongoing.

Preventative Action(s): Computerised

database being developed to include all

information specified in schedule 1 of

Regulation 28.

Post-Holder(s) responsible: CHO2 IT, Project

Manager.


9. The register did not include all

of the information specified in

Schedule 1 of these Regulations,

28 (2).

New

Corrective Action(s): New database being

developed to capture all information required

in the register of residents.

Post-Holder(s) responsible: CHO2 IT Project

Manager.


Preventative Action(s): Memo to be sent to all

staff reminding them to input data.

Post-Holder(s) responsible: Clinical Director.


Rules Governing the Use of Seclusion Report reference: Pages 62 & 63


10. Not all staff involved in physical

restraint had signed the policy log to

indicate that they had read and

understood the policy, 10.2(b).

New

Corrective Action(s): Policy signature log

to be maintained by all heads of

discipline confirming staff have read and

understand the policy.


discipline.

Verification of completed

signature log by head of

discipline.

Achievable. 1 month.

Preventative Action(s): All staff should

be requested to confirm that they have

read and understand the policy at

induction.


discipline.


11. In two seclusion episodes, the

resident was not informed of the

reasons, duration, and circumstances

leading to discontinuation of

seclusion. The explanation for not

telling the resident was not

documented in the clinical files, 3.6.

New

Corrective Action(s): Checklist is being

implemented for completion upon

discontinuation of seclusion.

Post-Holder(s) responsible: Regional

Practice Development Coordinator.

Audit. Achievable. Ongoing.

Preventative Action(s): Training schedule

on seclusion is being arranged with

practice development coordinator.

Post-Holder(s) responsible : Regional

Practice Development Coordinator

Course attendance list

confirming staff

attendance.


12. In two seclusion episodes, the

resident was not informed of the

ending of an episode of seclusion,

7.3.

New

Corrective Action(s): Checklist is being

implemented for completion upon

discontinuation of seclusion.


13. In one seclusion episode, the reason

for ending seclusion was not recorded

in the clinical file, 7.4.



Preventative Action(s): Training schedule

on seclusion is being arranged with

practice development coordinator.




confirming staff

attendance.


Code of Practice on the Use of Physical Restraint in Approved Centres Report reference: Pages 68 & 69


14. Not all staff involved in physical restraint had

signed the policy log to indicate that they

had read and understood the policy, 9.2 (b).

New

Corrective Action(s): Policy signature

log to be maintained by all heads of

discipline confirming staff have read

and understand the policy.


discipline.

Verification by heads of

discipline that all staff

have read and understand

the policy.

Achievable. 1 Month.

Preventative Action(s): All staff

should be requested to confirm that

they have read and understand the

policy at induction. Ongoing training

provided.


discipline.


15. In two cases, there was no record to indicate

that the resident had received a medical

exam at all by a registered medical

practitioner, within three hours after the

start of an episode of physical restraint by a

registered medical practitioner. In one case,

while a medical exam did take place there

was no time record to show that it took

place within three hours after the start of

the physical restraint episodes, 5.4.

New

Corrective Action(s): Training

schedule for medical staff to be

circulated and delivered by practice

development coordinator.




confirming staff have

attended training. Audit.


Preventative Action(s): Checklist to

be completed post restraint

prompting staff to meet regulations.



16. In two physical restraint episodes, residents

were not informed of the reasons for,

duration of, and circumstances leading to

discontinuation of physical restraint. The

reasons for not informing them was not

documented in either case, 5.8.

17. In two episodes of physical restraint the

resident’s next of kin was not informed

about the physical restraint and the reasons

for not informing them was not documented

in two cases, 5.9 (a).

New


schedule for staff to be circulated

and delivered by practice









be completed post restraint

prompting staff to meet regulations.

Post-Holder(s) responsible: All Staff.


18. In all three physical restraint episodes, there

was no documented record to indicate that

each episode of physical restraint was

reviewed by members of the multi-

disciplinary team and documented in the

clinical file within two working days after the

episode, 9.3.

New


schedule for staff to be circulated

and delivered by practice









incorporate post restraint review.



Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre Report reference: Pages 72 & 73


19. There was no documentary evidence that all

relevant staff had read and understood the

admission, transfer, and discharge policies,

9.1

New

Corrective Action(s): Policy

signature log to be maintained by

all heads of discipline confirming

staff have read and understand the

policy.

Post-Holder(s) responsible: All

heads of discipline.

Verification by head of

discipline that staff have

read and understand

policy.

Achievable. 1 month.

Preventative Action(s): All staff

should be requested to confirm

that they have read and

understand the policy at induction.

Ongoing training provided.

Post-Holder(s) responsible: Heads

of discipline.

As above. As above. As above.

20. The discharge plan did not include

documented communication with the

relevant general practitioner, 34.2.

New

Corrective Action(s): Memo sent by

Clinical Director to all medical staff

to ensure discharge plan is

completed in keeping with the

regulation.

Post-Holder(s) responsible: Clinical

Director.

Audit. Achievable. Completed.

Preventative Action(s):

Requirements of code of practice

on admission transfer and

Induction booklet detailing

requirements under the

code.

Achievable. 6 monthly.

discharge highlighted at induction

for medical staff.


Director.

21. The preliminary discharge summary was not

sent to the general practitioner within three

days, 38.3.

22. A comprehensive discharge summary was

not issued to relevant personnel within the

required timeframe of 14 days, instead it

was sent 23 days after the resident had been

discharged, 38.3 (b).

23. Discharge summaries did not include details

of prognosis, 38.4.

24. A timely follow up appointment, specific to

the needs of the resident, was not arranged

within one week post discharge from the

approved centre, 41.1 (c).

New

Corrective Action(s):

Correspondence sent by Clinical

Director to all medical staff

directing discharge summary to be

sent to GP’s within required

timeframe.

New initial discharge notification

duplicate book being developed to

send to GP on day of discharge.


Director.


3/12

Preventative Action(s): Circulate

code of practice to all medical staff

employed in the approved centre.


Director.

Medical staff to confirm

that they have read and

understand code of

practice.

Achievable. Complete.

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